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Long balloon overlap</li>
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Proximal MV stent oval deformation
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Repeat POT
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Use short balloons for KBI
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Asynchronous balloon deflation during KBI after accidental rewiring of the SB/aSB through a proximal strut
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The resulting neo-carina could be not in the centre of the bifurcation
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Repeat KBI with simultaneous balloon deflation
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Sequential use of balloons (NC preferably for the SB) with prolonged SB inflation and simultaneous balloon deflation
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SB/aSB dissection
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Oversized SB/aSB balloon
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SB/aSB stenting
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SB/aSB balloon (preferably NC) sized 1:1 to the SB/aSB diameter
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Difficulty in SB/aSB balloon removal after KBI
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Deflated balloon after KBI is entrapped in the pMV stent if the 3rd wire used to rewire the SB/aSB crossed abluminally in the pMV
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Do not pull strongly
Gentle balloon reinflation
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Avoid accidental abluminal rewiring into the pMV stent
Check with stent enhancement after complex steps or when in doubt
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MV stent extraction
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As described above when there is difficulty in SB/aSB balloon removal after KBI. Favoured by simultaneous balloon removal
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MV restenting
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As described above when there is difficulty in SB/aSB balloon removal
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Longitudinal MV stent deformation
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Guiding catheter not disengaged during removal of incompletely deflated balloons or of the SB/aSB jailed wire (see also the solutions of the same problem in Step 2)
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IVUS/OCT guided POT
Additional stenting (stent-in-stent)
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Guiding catheter disengagement when required
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Inability to perform additional balloon inflations or intracoronary imaging (IVUS/OCT) of the SB/aSB after KBI followed by POT because the balloon/imaging catheter stops:
a) at the proximal edge of pMV stent
b) inside the pMV stent at the SB/aSB ostium
c) in the aorta at the edge of LM stent
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SB wire jailed/trapped by the final POT after an incorrect SB/aSB rewiring in Step 3 with the wire:
a) (i) abluminally jailed in the proximal segment of the pMV stent (Figure 2, Panel 4a)
(ii) intraluminally jailed in the crushed proximal portion of the pMV stent (Figure 3, Panel 4a)
b) trapped by the final POT balloon inflated too distal after a proximal re-cross into the SB/aSB + KBI (metal neo-carina was repositioned at the SB/aSB ostium) (Figure 5, Panel 4a)
c) trapped after the abluminal passage into the LM from the aorta (Figure 6, Panel A)
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a) (i) Figure 2 (Panel 4c with text description in the main body)
(ii) Figure 3 (Panel 4c with text description in the main body)
b) Figure 5 (Panel 4c with text description in the main body)
c) Figure 6 (Panel C and D with text description in the main body)
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Proximal 2nd POT when required in Step 2
Stent enhancement angiographic visualisation to increase precision of POT balloon positioning (after proximal SB/aSB rewiring and creation of a metal neo-carina)
Intracoronary imaging (IVUS/OCT) to confirm the wire position in case of suspected abluminal SB/aSB rewiring
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IVUS: intravascular ultrasound; KBI: kissing balloon inflation; LM: left main; MV: main vessel; NC: non-compliant; OCT: optical coherence tomography; pMV: proximal main vessel; POT: proximal optimisation technique; PS: provisional stenting; SB/aSB: side branch/assigned side branch
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